Form 13614-T Telephone Excise Tax Refund Form 1040EZ-T Intake Sheet

Form XXXXX Revised 11/14/06

Telephone Excise Tax Refund 1040EZ-T INTAKE SHEET

OMB # xxxx-xxxx

All information will be treated confidentially  Return Preparation services are free.

• Did you pay for long distance telephone service after February 28, 2003, and before, August 1, 2006?

If no, STOP – You do not qualify for the Telephone Excise Tax refund.

• Did you receive or have you requested a refund of the taxes you paid from your long distance service provider?

If yes, STOP – You do not qualify for the Telephone Excise Tax refund.

• Can you be claimed as a dependent on the income tax return of any other person for 2006?

If yes, – You must file Form 8913 to claim the Actual Taxes Paid.

• Have you or will you file a 2006 Federal Income Tax return?

If yes, STOP – Do not complete the1040EZ-T

• Did you have wages or self-employed income in 2006?

If yes, STOP – Do not complete the 1040EZ-T

PERSONAL INFORMATION

________________________________ _____ ________________________________ _______-______-________

Your First Name MI Last Name SSN or ITIN

________________________________ _____ ________________________________ _______-______-________

Spouse’s First Name MI Last Name SSN or ITIN

Address: __________________________ Apt # _______ City ______________________ State____ Zip ________

Phone numbers: Daytime ________________ Evening _________________ Cell ___________ _______

Personal and Dependent Information

List all persons for whom you provided support in 2006:

	Person 1	Person 2	Person 3	Person 4
Name
Birth Date
Relationship to you (son, daughter, parent, etc.)
Number of months this person lived in your home during 2006
Is this person a US Citizen, US Resident, or Resident of Mexico or Canada?
Did you provide more than 50% support for this person in 2006?
Did this person provide less than 50% of their own support in 2006?
Was this person’s income less than $3,200 in 2006?

If you had Earned Income in 2006 you may be eligible for the

Earned Income Tax Credit (EITC) or other Credits